6/26/2012

1

Today’s Session: Engage Frontline Staff & Prioritizing Portfolios

Kathy Luther, RN, MPM

Jill Duncan, RN, MS, MPH

These presenters have nothing to disclose

WebEx Quick Reference

• Welcome to today’s session!

• Please use Chat to “All Participants” for questions

• For technology issues only, please Chat to “Host”

• WebEx Technical Support: 866-569-3239

• Dial-in Info: Communicate / Join Teleconference (in menu)

Raise your hand

Select Chat recipient

Enter Text

6/26/2012

2

When Chatting…

Please send your message to

All Participants

If you’re joining with colleagues, please type the organization you represent & the number of

people joining from your organization.

Example: Midwest Health Alliance – 3

Please type your name and the organization you represent in the chat box!

Example: Chris Jones, Midwest Health Alliance

6/26/2012

3

IHI Expedition Team

Kathy Luther, RN, MPM

Vice President, IHI

Jill Duncan, RN, MS, MPH

Director, IHI

Kayla DeVincentis

Project Coordinator

Today’s Guest Faculty

Angela Graham, RN, MSN, Director of Outcomes Management King’s Daughters Medical Center

Jennifer Harrington, Vice President, Clinical and Support Services Anne Arundel Medical Center

6/26/2012

4

Agenda

• Welcome & homework review

• Understanding categories of waste

• Identifying waste at the front line

• Beginning to describe the financial impact and potential savings associated with removing waste

• Case study examples

• Wrap up and next steps

• Evaluate Cost & Quality Impact

• Prioritize Projects and Manage Organizational Energy

• Create a Portfolio of Projects

• Solve Problems and Execute PDSA Cycles

• Measure and Monitor Results

PRIMARY DRIVERS SECONDARY DRIVERS

Reduce operating

expenses 1% per

year while continually

maintaining or

improving quality.

AIM

WILLAlign Enterprise

WILLEngage Staff, Physicians and Patients

IDEASIdentify Waste

EXECUTIONPrioritize, Manage Portfolio of Projects to Remove Waste

• Establish True North Metrics (Big Dots)

• Align Waste Reduction Strategy Throughout Organization

• Align Systems for Efficiency

• Adopt Integrated Performance Measurement Systems

• Engage Staff in the What & Why of Value Delivery

• Establish Data & Feedback Loops

• Patient & Family Perspective of Waste

• Ensure a Safe Environment for Sharing Ideas

• Develop New Skills at All Levels

• Eliminate Clinical Quality Problems

• Optimize Staffing

• Maximize Flow Efficiency

• Manage Supply Chain

• Reduce Mismatched Services—overuse, coordination

• Reduce Environmental Waste (Healthy Hospital Initiatives)

Driver Diagram IHI’s Cost + Quality Collaborative Work

6/26/2012

5

1. Agree on an approach (either by service line, across your organization or within a specific department)

2. Identity an aim (dollar aim; cost/case or cost/discharge)

3. Clarify your team and the roles of each member

Send ‘Tweet’ of 140 characters or less to Jill at jduncan@ihi.org by Friday, June 22nd

Homework Review

Ground Rules

We learn from one another – “All teach, all learn”

Why reinvent the wheel? - Steal shamelessly

This is a transparent learning environment

All ideas/feedback are welcome and encouraged!

6/26/2012

6

We are looking at

o the top 10 opportunities and Cost per case

o the team is the Charge Compliance taskforce

o across the organization until we identify departments with higher opportunity

Robin Zudell RN, CPHQ

Clinical Outcomes Manager, Performance Improvement

Queen of the Valley Medical Center; Napa, CA 94558

“AHS will be applying this expedition to 2 clinics as an initial pilot with an aim of saving a % of operating

costs with the involvement of quality, operations and finance teams"

UH Rainbow Babies and Children’s/MacDonald Women’s Hospital

1. Across the organization

2. Achieve a 25% decrease in hospital costs related to Serious Safety Events throughout Rainbow

Babies and Children’s by December 31st, 2012.

3. Members of Quality Team and Finance will work together to determine costs of Serious Safety

Events from hospital baseline period.

Stephen Czekalinski, MBA, RN, BSN

Quality Improvement RN

Rainbow Babies & Children's Hospitals

Analyze catheter associated UTI, including $ impact of Medicare reimbursement. Per case analysis

based on 2011 baseline number of cases. - - - Virginia Mason Medical Center

Review, analyze both quality & financial consideration for our top admitting diagnosis ( Pneumonia with

and without complications) and make recommendations for better outcomes.

(Decrease readmission rates, increase revenue, better outpatient management, improved processes ,

better core measures, etc)

Brenda L Sturm MSN FACHE

Vice President, Nursing

Daviess Community Hospital

6/26/2012

7

Approach:

For FY13, Harborview has embarked on a project to review practice variation with the focus to decrease

unnecessary variation. HMC’s approach will be multi-faceted starting with service lines and managed

across the departments based on utilization, including external benchmarking. First quarter services

include: Spinal Surgery, Opthalmology and Thoracic Surgery.

Dollar Aim

$1,735,000 over FY13 (7/1/12 – 6/30/13) accumulative across all services, inpatient & outpatient. This

amount is a smaller portion of the HMC FY13 Performance Improvement Initiative goal of $23.6 million

Team

Performance Improvement membership includes executive operational leadership including CNO,

Administrators for inpatient and outpatient divisions with finance and chiefs of staff and key physician

leadership within the service. Each service review will include department management and directors as

well as chief of service and service physician leadership.

Denise M. Leverentz

Director, UW Medicine Finance Decision Support

1. Agree on an approach (either by service line, across your organization, or within a specific

department): we have chosen to take a service line approach to examine the cost of Cataract

Surgery in our hospital. The reason being, the government (our single payor) is going to

reimburse us at a higher level per case, but we still don't know whether we will be making a

profit or not. This would determine whether or not we increase volume.

2. Identify an aim (dollar aim; cost/case or cost/discharge): the aim is to establish a cost/case

3. Clarify your team and the roles of each member: team members include- myself (Chief of

Surgical Services and Interim COO); Nursing Director for Surgical Services; MD MBA student

who is actually doing the data collection

McGill – Montreal, Canada

Royal Commission Medical Center Yanbu Industrial City - KSA

IHI Expedition:

Partnering Quality & Finance Teams to

Improve Value

6/26/2012

8

Assignment # 1

1. Approach: department-specific projects

2. Aim: 1-3% reduction in the cost/bed/year (may be revised)

3. Team members: a) Dr. Alber Paules (Quality Officer – Quality Improvement Dept.)

b) Mr. Ahmed Saleh Al-Amri (Receptionist – Patient Affairs Dept.)

c) Radhwan Khedher Al-Ameer (Payable Manager – Finance and Budget Dept.)

d) Mr. Hani Ibrahim Al-Ogaibi (Customer Services Officer – Patient Affairs Dept.)

e) Mr. Mohamed Azrae (Budget Specialist – Finance and Budget Dept.)

f) Ms. Hessah Faisal Al Refai (Auditor Salaries Specialist – Finance and Budget Dept.)

g) Ms. Yusra Naeem Qari Tilbay (Customer Services Officer – Patient Affairs Dept.)

h) Mrs. Salma Khaled Baabbad (Bank Guarantee Specialist - Finance and Budget Dept.)

i) Other members may be added from the following departments: InfectionControl and OR.

Portfolio Management• Aim of Portfolio:

• Current Portfolio Projects:Project Name Projected

Savings Savings to

DateQuality Metrics

Reducing unnecessary extra patient daysresulting from cancellation of scheduled ORprocedures.

SAR - To be calculated

SAR

Reducing unnecessary extra patient daysresulting from the prolonged stay of inpatientsdue to poor coordination of the processesassociated with discharge.

SAR - To be calculated

SAR

Reducing avoidable extra patient days resultingfrom the patient stay inside the ICU due toacquiring ventilator-associated pneumonia(VAP).

SAR - To be calculated

SAR

Reducing unnecessary admissions at theweekends for patients who are scheduled forsurgery at the beginning of the new week.

SAR - To be calculated

SAR

SAR - To be calculated

SAR

Percentage of Operating Budget

Savings in Saudi Riyals

6/26/2012

9

Thank you!

Looking for “Waste”

• Variation from benchmarks

• The usual suspects

- pharmacy, supply chain, overtime hours, delays

• Lean strategies – reduce process steps, staff “steps”, supply waste, etc.

• Top down strategies –often budget driven

6/26/2012

10

Keys to Success

• Find and categorize “waste”

• Identify potential projects

• Clinicians and finance work together to develop financial models

• Prioritize projects using criteria:

─Ease of implementation

─Linkage with other efforts

─Estimated $$ amount

• Measure progress, $$ weekly @ start

One way: Waste Identification Tool

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/HospitalInpatientWasteIDToolWhitePaper.aspx

Developed in

partnership with the UK

– Health Foundation

6/26/2012

11

Establish a Realistic Portfolio for Waste and Cost Reduction

Identify PotentialWaste Streams

Many Methods•Waste ID Tool•Dashboards•Benchmarking•Mimic Other’s Projects

Waste, Cost, and Quality Assessment

•Finance engages with potential waste initiatives•Data collection and analysis verifies opportunity•Plan to capture $ and redeploy bottom line

Build and Execute a Portfolio

•Select initiatives considering goals and environmental realities•Integrate waste initiatives into organizational goals•Execute on the initiatives with leader support•Capture $ and redeploy

Realistic,EffectivePortfolio Of Projects

Front Line Engagement

6/26/2012

12

Customization and Adaptation

Benefits

• Engages front line staff

• Speaks with “data”

─How often?

─Where?

• Sets up staff to help drive change

6/26/2012

13

Waste Identification Tool Worksheet

Ward Module Clinical Waste

Unit___ICU patients Reviewers_____Dr. Intensivist

Date___Wed, ___________

Bed ID Waste Waste Waste Streams

Yes No Nosocomial

Infection

Adverse

Drug Event

Procedure

Complication

Unnecessary

Hospitalization

Flow Delay Clinical Care

Delay

Comments

T-1 X Awaiting PICC IR

T-2 X X Lap chole comp 12/25

T-4 X X Futility EOL,family

T-5 X X

T-7 X X No Plan

T-8 X X No drip on floor. Pt walking

around ICU

T-9 X

T-10 X X No (insulin) drip on floor

B-S X X No OR til Fri

B-T X X X Card. Consult, no family

meeting, EOL

B-O X X Pt fell, No OR til Fri

B-S X

C-M X X End of Life (EOL)

C-A X

C-J X X Trach Collar trial not done

V-R x X Awaiting trach & G-Tube

V-A X X X Inf & EOL futility

V-A X X X Pneumothorax, & EOL

futility

V-P X X X Graft inf. & hematoma Total # of wasted beds the numerator ______16____________

Total # beds reviewed the denominator ______19____________

% waste ______84%____________ Return to Kathy Luther R789 713 704-7236

Memorial Hermann– TMC

6/26/2012

14

Process Steps

• Select an area (unit or patient condition)

• Identify staff who “see waste”

• Identify categories of waste – include “other”

• Customize worksheet

• Develop implementation plan

─Short test cycles – shift, unit, patient, process

• Aggregate categories of “waste”

Waste Tool: Customization

6/26/2012

15

Interim Healthcare (Homecare) Front Line Staff Interviews Using Waste ID Tool

Branch

Patient

ID

YES NO

Patient Non-

Compliance

(PNC)

Patient

Unavailable

for Service

(PUS) Flow Delay

(FD)

Clinical

Care Delay

(CCD)

UA PI ME SG UT UM UP PNC PUS ES UMS AE CM AI FD CCD

Waste* Waste Streams

Unnecessary Admission

(UA)

Patient Ineligible (PI)

Visits more than:

Medically Necessary

(ME)

Unnecessary:

Testing (UT)

Monitoring (UM)

Excess supplies (ES)

Unneccesary medical

suppies (UMS)

Potential avoidable adverse event

(AE)

Complication (CM)

Definition of Waste: Any activity that does not benefit the service user (could be patient, internal/external customer): Adverse Events/Comp; Inappropriate use of clinical services; Delays/Lack of

Coordination: If a category does not apply enter “No”

Date & Time of Review Reviewer(s)

Branch/Patient Care Module Instructions

INSTRUCTIONS

Determine the number of patients for the branch. This is the TOTAL PATIENTS

REVIEWED. Each patient should be noted on the worksheet in the “Patient ID” column,

noting each with their medical record number. Note also the name or initials of the primary case manager for each patient. Note the number of total patients reviewed in the

space for “Total Patients Reviewed.”

Direct communication with clinician case managers is recommended for this module. Use review of case notes or patient records only for information that cannot be obtained or if

case managers are not available.

Waste Type Definitions:

Unnecessary admission(UA):

� Any homecare admission when a defect in care caused

admission/readmission

Patient ineligible(PI):

� Not homebound, no skilled need

Visits more than necessary frequency (ME):

� Visits provided with repetitive/ineffective “skill” versus “impact” visits, i.e.

therapy visits less than 45 minutes in length � Multi-discipline therapy (OT, PT, ST) visits provided on same day

� SN education visits less than 40 minutes or teaching same thing repetitively

Visits more than standardized visit guidelines(SG)):

� Visits above that recommended by chronic disease management guidelines

Unnecessary test(UT):

� Tests repeated due to lost/inappropriate specimen collection

Unnecessary monitoring(UM):

� Prothrombin time checks beyond therapeutic results for 2 weeks � Home telemonitoring for noncompliant patient, patient with therapeutic

management or lack of benefit to patient or health status

� Glucose monitoring for patient with therapeutic results or noncompliance

Unnecessary procedures(UP):

� Daily dressing changes beyond 2 weeks

� Unnecessary invasive device: urinary catheter changes, infusion line maintenance, etc. past when device should be discontinued

Patient non-compliance(PNC):

� Use of services to patient non-compliant with overall care

regimen

Patient unavailable for service(PUS):

� Patient unable to be located

� Requiring multiple contacts to schedule--total attempts to contact patient to schedule visits exceed 2 times

Excess Supplies provided(ES):

� Supplies taken out to home in excess of patient need--

more than 1 week supply in home at any given time

Unnecessary medical supplies provided(UMS):

� Wrong supplies delivered/taken to home

Potentially avoidable adverse event(AE):

� Medication related events, i.e. errors, adverse reactions

� Fall at home with injury

� Hyper/hypoglycemia

Complication(CM):

� Worsening of or development of pressure ulcers

� Anticoagulant related bleeding � Dehydration

Agency acquired infection requiring avoidable extended home care

service, ER or hospitalization(AI):

� MRSA, C.diff, UTI, Wound infection, infusion

site/bloodstream infection, urinary catheter infection

� Other

Flow Delay(FD):

� Delays in care transitions resulting in patient continuing

to be active versus transferred, i.e. awaiting hospice/facility transfer decision

Clinical Care Delay(CCD) :

� Delays in the delivery of clinical care that result in the patient remaining active, i.e. procedures/tests not able to

be done or delayed; or care coordination

ineffective/delayed/not completed

Northeast Medical CenterEnvironmental Services (Customized) Waste Tool

HOSPITAL WASTE IDENTIFICATION TOOL- EXAMPLE

Campus__Samaritan Department_Environmental Services Job Title of Person Completing: Environmental Services Associate_

Instructions: Log the location, date and time and place a check mark in the appropriate column for the type of waste identified

WASTE TOPICS (EXAMPLES)

Unit/ Area of

Hospital

Room Number

(if applicable)

Date/ Shift Discharge

Log Books

not

Accurate

Flow

Delay

Isolation Procedure

not accurate

Nursing

Item not

Removed

Poor Infection

Control

Practice

Observed

Other Waste

Identified

Comments

509-A 12/13- D X X X

210-A 12/14-D X X X

601-B 12/14-D X X X

403-B 12/6-D X X X

# Waste Topics Identified

(Optional)

Total

Observations

(Optional)

% Waste

*** Red column headings may be modified or customized to capture waste issues that are not listed.

6/26/2012

16

Finding Waste: Examples

• ICU -- inappropriate admissions (3 per week)

• Home care: wound care protocols

• CLABSI’s beyond ICU tracking

• Outpatient/EC/ UrgiCare visits

• Lots of “waste tools”:

─Call light logs

─OR cancellations

─Avoidable days

• Choosing wisely (ABIM)

What’s the Cost

Finance

• Spreadsheets

• Aggregate numbers

• MS- DRGs, icd-9s

• Averages, means

• Services, service lines

• Payor class

Clinicians

• Charts

• Patients—one-at-a-time

• Conditions

• “Worst case”

• Complicating factors

• Social factors

6/26/2012

17

Financial Models: Clinicians & Finance

• Which patients?

─ Identification – condition, admit source, unit– DRG, APR-DRG, principle diagnosis

─ Inclusion-exclusion criteria– Age, chronic conditions,

• Final model?

─ Literature based

─ Case match

─ Historical costs, actual costs, cost/charge ratio

• Size of sub-sets

• Cost of sub-sets

Approaches to Cost Identification

• Case match

• Pre and post

• Condition – heart surgery, pneumonia

• Flow, delays

6/26/2012

18

Case Match

When to use

• Conditions that are independent of DRGs or diagnoses (HAIs)

• Ability to subset data by a variety of criteria

• Large enough patient group

Example -Sepsis as complication

• Inclusion criteria

─ Age <90

─ LOS day, ICU day (<30 days)

─ Diagnosis, condition

─ Admit source, primary diagnosis

• Develop data set of patients with sepsis

• Analyze by admit source, age, M/F, diagnosis, LOS

• Case match with similar non-septic patients

Steps

• Identify “event”

• Agree on inclusion criteria

• Develop and vet data set

Before and After

When to use

• Conditions that are independent of DRGs or diagnoses (HAIs)

• Ability to identify patient population

• Large enough patient group

Example -Sepsis as complication

• Inclusion criteria

─ Age <90

─ LOS day, ICU day (<30 days)

─ Diagnosis, condition

─ Admit source, primary diagnosis

• Develop data set of patients with sepsis

• Analyze by admit source, age, M/F, diagnosis, LOS

• Follow the same data set

over time

Steps

• Identify “event”

• Agree on inclusion criteria

• Develop and vet data set

6/26/2012

19

Patient Condition

• Identify condition

• Flowchart process steps

• Identify “start” and “stop”

• Set up cost model – over all, and by step

• Identify waste at each step

• Identify “cost” of waste at each step

HomeMD

officeUrgi-care ED

Hospital floor

HospitalICU

OR

Flow and Delays

• Identify area of focus

─ ED, ICU, OR, Ambulatory

• Consider cost associated with delay

─Staff overtime

─OR “down time”

─Extra beds needed/avoided

─More patients seen–with same resources

• Model cost based on type of delay

– Hours, OR case, increased capacity

6/26/2012

20

• Worked with MDs in Medicine Service Line • Category Identification – ICUs, Floors, Observation

unit --- Care/clinical delays specific to each area ─ Consultation, procedure and test delays─ End of life –discussions, decisions─ Inappropriate admissions─ Adverse events ─ Sedation management─ Delays in treatments- extubation, ambulation,─ Types of patients– level of care ─ Repeated labs with care team/unit change

Waste Tool to Projects: Medicine

Topics Identified

• MICU

─Delays in procedures, tests, consultations, end of life discussions, handoffs

─ABG testing– particularly vent weans

─Repeated labs from EC to MICU transfer

• Hospitalists

─Patient populations: Sickle Cell, Chest Pain (non-cardiac evaluation)

─Repeat reference tests – for known conditions-(eg: HIV status)**

─Serial lab tests ** (lab techs)

6/26/2012

21

Waste Project PortfolioMedicine Service Line

Financial Implications in the Current System

Impact on Quality

Substantial Cost Savings Moderate Cost Savings

Negative Impact-nosavings or loss

High •Sickle Cell management ($450K/ year)•Chest Pain management ($ 400K/year)

•To be evaluated: ICU days awaiting consultation, procedures, end of life discussions

•EC – MICU admits (duplicate tests on MICU admit)

Moderate ABG testing $15 K •Confirmatory tests•Repeat tests

•Supplies

Case Studies

6/26/2012

22

King’s Daughters Medical Center

Angela Graham, RN, MSNDirector of Quality Outcomes

Angie.graham@kdmc.net606-408-4918

Idea Bank

• Inception: December, 2007-was to be a 6 month program─Total Savings/Revenue generation $9.65 million─Team Member payout of $165,000

• Allow front-line team members to submit cost-saving ideas for a portion of the savings.

• Online tool that allowed idea submission to be easy for the user

6/26/2012

23

Examples of Ideas

• Cath Lab and Radiology-change type of contrast & vendor

─ $137,000

• Switch closure devices (Boomerang and angioseal) to Syvek patch for cardiac cath

─ $77,000

• Common canister program for MDI

─$447,000

• Changed suture vendor

─$27,000

Continued…

• Eliminated “free food” for physicians and vendors in the café

─$72,000

• Bundle patient care items into kits

─$37,000

• Leased printers instead of purchasing

─$102,000

• Reduced cost and use of free car seats to new mothers

─$51,000

6/26/2012

24

Waste Identification Tool

• Utilized by the Vice President Group in the beginning

─Bi-weekly rounding to identify processes that failed the patient and the team

─ Identified opportunities for improvement in:

�Laboratory

�Radiology

�Cath Lab Scheduling

WIT: Fueled Projects

• Cath lab scheduling process:

─48 steps to 8

─Biggest surprise-physician involvement!

• Laboratory equipment

─Less “send outs”, more done in house

─Cost of machinery/technology did not outweigh

• Length of Stay

─Quickly identified who couldn’t “pull the trigger”

6/26/2012

25

WIT: Making a Comeback

• Today…fueling A3 projects around the

organization

• Identifying potential “just do-it’s” or Rapid Improvement Projects

• LEAN methodology

Contact Information

Angela Graham, RN, MSN

Director of Quality Outcomes

Angie.graham@kdmc.net

606-408-4918

6/26/2012

26

Anne Arundel Medical Center

About Us

• Anne Arundel Medical Center– Located in Annapolis, Maryland

– Entity of Anne Arundel Health System

FY11 Admissions 25,289

Licensed Beds 336

FY11 Emergency Visits 76,288

FY11 Outpatient Visits 86,166

• Cost and Quality Team – Anastasia Brown, Director of Quality and Regulatory Affairs

– Jennifer Harrington, VP, Clinical and Support Services

– Anne Marie Pessagno, Senior Director, Nursing

– Bob Reilly, Chief Financial Officer

– Mitch Schwartz, Chief Medical Officer

6/26/2012

27

Anne Arundel Health System Project Portfolio Status Update

HQLC Projects

FY12 FY12

Quarter 1 Quarter 2

1 Throughput 2 3

2 VTE Prophylaxis 3 4

3 Point of Care Testing 2 2

4

Surgical Services Charge Capture Workflow

Redesign 4 4

5 Clatanoff Charge Capture Workflow Redesign 3 3

6 Routine monitoring of Stroke Key Indicators 4 4

7 Reduction of Annual Film cost 3 4

8

Utilization of Adjusted Body Weight vs Actual Body

Weight to Dose Intravenous Immunoglobulin 4 4

9 Standardization for Robotic Instrumentation 3 5

10 Worker's Compensation Transitional Duty Program 2 3

11 OPIV scheduling and Charge Per Visit 1 1

12 Decreasing Duplicate Dispensing Waste 3 4

13 Outpatient IV Therapy for Newborns 4 4

14 Adult Hospitalist Charge Capture 3 3

15 Post Discharge Follow-up Appointments 2 3

16

Perioperative Cardiac Assessment Prior to Surgical

Procedures 1 1

17 Reduce Use of Foleys 2 3

18 Joint Center Improvement Process 3 3

19 Catheter Team 1 1

20 Catherization Lab Operational Improvements 3 3

21 Ordering Patterns 2 2

22 Ventilator Liberation 1 3

23 Discharge Summaries 1 1

24 Operating Room Purchasing Practices 2 2

25 Time of Service Collection Capture 2 0

26 Recall Storage Facility Rental Fees 2 2

27 Supply Chain Automation 3 3

28 Surgery Operations 2 2

29 Surgical Services Hyland Scanning 1 Q3

Project Progress Scale

0 – Non-starter1 – charter established2 – activity, but no changes3 – Modest Improvement4 – Significant Progress5 – Outstanding Success

Approved and proceed in respective quarter

Approved and proceed in respective quarter, however resource availability may require timeline adjustment

Define expected results and resources and move for executive approval

Primary Drivers Secondary Drivers Projects

Dark Green Dollars

Reducing Operating

Budget by 2% a year

Clinical Quality

Problems

Staffing

Flow

Supply Chain

Mismatched

Services

Mass Purchasing

Pharmaceuticals

Wasted Materials

Operating Room Purchasing

Supply Chain Automation

Hyland Scanning Duplicate Dispensing

Reduction in Film Cost Robotic Instruments

Weight Based IVIG Film Reduction

Recurring OPIV

Turnover/Recruitment

Premium Pay

Work Days Lost Due to

Injury/Illness

Workers Compensation Program

Malpractice claims

Coordination of Care

Adverse Events and

Complications

Ventilator Liberation Jt Center Outcomes

VTE Prophylaxis Stroke Indicators

Foley Reduction Meaningful Use

Readmissions

Catheter Team

Waste in Admin Services

End-of-Life Care

Unnecessary Procedures/

Hospitalizations

Charge Capture (Surgical and Clatanoff)

Recall Storage

Newborn OPIV

Ordering Patterns

Radiology Ordering

Match Capacity :Demand

Hospital Throughput

Ancillary Throughput

Inpatient Throughput

Surgical Operations Point of Care Testing

Periop Cardiac Assessment

Cath Lab Operations

Circles indicate

primary focus of

efforts

6/26/2012

28

Sample Portfolio Management

Project

(add rows as needed)

Projected Savings Bottom Line Impact

to Date

VTE $ 45,000 $16,000

Foley Reduction $47,000 $9,000

Supply Chain Automation $1,000,000 $187,000

Robotic Instrumentation $250,000 $72,000

Weight Based IVIG $315,000 $75,570

NICU OPIV $170,000 $47,000

Premier Pharmacy Engagement $90,000 $25,000

Adult Hospitalist Charge Capture $380,000 $253,000

OR Purchasing Practices $800,000 $87,000

Reduction in Annual Film Costs $300,000 $45,000

Barriers and Breakthroughs• Challenges

– Establishing buy in regarding process steps (i.e. charter development)

– Prioritization of projects

– Misunderstanding of intentions

– Creating a culture of discipline

– Financial modeling

• Opportunities

– Accountability measures

– Identification of organizational energy

– Selection of Lean methodology to utilize throughout the health system

6/26/2012

29

Portfolio Management Now

• Implementing Lean methodology across the Health System

• Establishing project priority based on ability to move the True North Metrics

– Human Development

– Timeliness

– Cost

– Quality

– Growth

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Total 0 0 0 0 0 0 0 0 0 0 0 0

Simpler #D IV / 0! #DIV / 0! #DI V/ 0! #DI V/ 0! #DI V/ 0! #DI V/ 0! #DI V/ 0! #DI V/ 0! #D IV/ 0! #D IV / 0! #D IV / 0! #DIV / 0!

Client

% Realized Savings vs . Potential

3 # Teams YTD

2 0 0 0 0 0 0 0 0 0 0 0

Potential Savings

-$

0 0

Savings $

ROI Ratio

0 0 0 0 0 00

0

-$ -$

0

0 0

-$

-$ -$

-$

-$

-$

-$

-$ -$

-$ -$

-$

0

-$ -$ -$ -$

-$

-$ -$

# DIV/ 0!

-$ -$

-$

-$ -$

0

-$ -$

-$

00 0 0

-$

0

0

-$

-$

-$

-$

-$

0

0

00

00 00 0 0 0

1 2 0

0

($) M

($) Q

($) T

($) C

KPI M

C o sts o f Event Week

KPI Q

KPI T

KPI C

P ro duct iv ity

D elivery

Total

Before

After

After

V SA pro jected po t entia l return 0 0 0 0

000 0

Quantity

A rea Description

0 00

VS A's C o nducted to

Date

-$ -$ -$ -$ -$

# DIV/ 0! # DIV / 0! # D IV/ 0! # D IV/ 0! # DIV / 0! # D IV/ 0! # D IV/ 0!

Number R IE T eams # / M O To Date 0 0

# D IV/ 0!

P ro jected hard savings annualized -$ -$

-$ -$

0

S atisfactio n Surveys

C o llectio ns

0 0

C apacity

Q ualit y

M o rale

Delivery

Total

0 0 0

0

0 0 0 0

-$

-$

-$

-$ -$

-$

-$

-$

-$

-$

-$ -$ -$ -$

-$ -$

Before

Before

Total -$

-$

-$

-$ -$

0

Annualized

0

-$

0

-$

After

Before

Total

0 0Total

Before

After

0

-$

0

0

-$ -$ -$ -$ -$ -$

-$ -$ -$ -$

-$

-$

-$ -$ -$

-$

Jul A ug

Quality -$ -$

-$

-$

-$ -$

#DIV/0!

Total -$

Before

-$

After

-$ Productivity -$ -$ -$

0 0

-$ -$

A pr

-$

-$

Morale

Site Level MeasuresSite Level MeasuresSite Level MeasuresSite Level MeasuresJan F eb M ar Jun

-$ -$

M ay

-$

-$ -$

O ctSep N o v D ec

-$

-$ -$

# DIV / 0! # D IV/ 0!

-$ -$ -$

Ret urn On Investment Ratio # D IV/ 0!

After

Before

After

Before

Total

0

O n T ime D elivery

After

0

0

0

0

0

1

1

1

1

1

1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Human Development

Morale

0

0

0

0

0

1

1

1

1

1

1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Quality

Quality

0

0

0

0

0

1

1

1

1

1

1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Timeliness

Delivery

0

0

0

0

0

1

1

1

1

1

1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Cost Savings

Productivity

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

$0

$0

$0

$0

$0

$1

$1

$1

$1

$1

$1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Return on Investment

Savings $ ROI Ratio

6/26/2012

30

Follow Up Contact

Jennifer Harrington

Vice President, Clinical and Support Services

jharringto@aahs.org

443-481-4830

Summary

6/26/2012

31

Questions?

Raise your hand

Use the Chat

Resources

• Berwick, D, Hackbarth, A (2012). “Eliminating Waste in US Health Care.” JAMA 307(14).

• Cocanour, C. S., L. Ostrosky-Zeichner, et al. (2005). "Cost of a Ventilator-Associated Pneumonia in a Shock Trauma Intensive Care Unit." Surgical Infections 6(1): 65-72.

• Caldwell, C, et al. “Cost Reduction in Health Systems: Lessons from an Analysis of $200 Million Saved by Top Performing Organizations”

• Eber, M. R., R. Laxminarayan, et al. "Clinical and Economic Outcomes Attributable to Health Care-Associated Sepsis and Pneumonia." Arch Intern Med 170(4): 347-353.

• Edwards et al (July 2011). “Achieving Efficiency: Lessons from Four Top-Performing Hospitals.” The Commonwealth Fund.

• Martin, L., C. Neumann, et al. (2009). Increasing Efficiency and Enhancing Value in Health Care: Ways to Achieve Savings in Operating Costs per Year. IHI Innovation Series white paper. Cambridge, Massachusetts, Institute for Healthcare Improvement.

• Wallace, J, Savitz, L (2008). Estimating Waste in Frontline Health Care Workers, Journal of Evaluation in Clinical Practice, 14:178-180

• Hospital Inpatient Waste Identification Tool (www.ihi.org) http://www.ihi.org/knowledge/Pages/IHIWhitePapers/HospitalInpatientWasteIDToolWhitePaper.aspx

6/26/2012

32

Partnering Quality and Finance Teams to Improve Value

Expedition Worksheet

Align senior support

Decide where you want to start

Begin to build a partnership with leaders from the finance team

What is your aim? (% operating expenses? Cost/case? Cost/discharge?)

Engage frontline staff

Begin to identify projects that will get you to your aim

Begin building a portfolio

Consider projects you are already working on as potential for your portfolio

Don’t know where to start? Consider adapting and testing the Waste

Identification Tool

Build and leverage

partnerships

Collaborate with your financial colleagues to review your suggested portfolio

and identify what might get at dark green dollars.

Develop financial

models

Define how you will measure the potential and actual savings for each

project

Monitor quality to

assure improvement

Identify best practices, financial models, aims & charters for each area of

work

Develop a series of projects around the ones identified by your team (your

portfolio)

Develop a sequencing plan for the work

Test improvement interventions as well as financial measurement strategies

Implement systems to encourage rhythm and discipline around the work

Track progress

Learn & spread across a

community

Spread learning and best practices

Re-engage & re-commit on a regular schedule

Partnering Quality and Finance Teams to Improve Value

Expedition Worksheet

Align senior support

Decide where you want to start

Begin to build a partnership with leaders from the finance team

What is your aim? (% operating expenses? Cost/case? Cost/discharge?)

Engage frontline staff

Begin to identify projects that will get you to your aim

Begin building a portfolio

Consider projects you are already working on as potential for your portfolio

Don’t know where to start? Consider adapting and testing the Waste

Identification Tool

Build and leverage

partnerships

Collaborate with your financial colleagues to review your suggested portfolio

and identify what might get at dark green dollars.

Develop financial

models

Define how you will measure the potential and actual savings for each

project

Monitor quality to

assure improvement

Identify best practices, financial models, aims & charters for each area of

work

Develop a series of projects around the ones identified by your team (your

portfolio)

Develop a sequencing plan for the work

Test improvement interventions as well as financial measurement strategies

Implement systems to encourage rhythm and discipline around the work

Track progress

Learn & spread across a

community

Spread learning and best practices

Re-engage & re-commit on a regular schedule

6/26/2012

33

Homework for Next Call

1. Test the Waste Identification Tool in at least 1 clinical or support service area

2. Bring results back to a multi-disciplinary team

3. Identify and define potential “waste streams”

4. Define data collection process

5. Collect and categorize “waste”

6. Identify at least 3 projects for your portfolio; could include current projects or new opportunities

Send ‘Tweet’ of 140 characters or less to Jill at jduncan@ihi.org by Monday, July 9th

Expedition Listserv

If you would like additional people to receive session notifications please send their email addresses to

improvementmap@ihi.org.

We have set up a listserv for participants in this Expedition to share improvement strategies, and

pose questions to one another and faculty.

To use the listserv, address an email to

QualityFinanceExpedition@ls.ihi.org

6/26/2012

34

Schedule of Calls

• Session 1 – Tuesday, June 12th 1:30 – 3:00 EDT

─ Align senior support & build and leverage partnerships

• Session 2 – Tuesday, June 26th 2:00 – 3:00 EDT

─ Engage frontline staff & prioritize portfolios

• Session 3 – Tuesday, July 10th 2:00 – 3:00 EDT

─ Develop financial models

• Session 4 – Tuesday, July 24th 2:00 – 3:00 EDT

─ Monitor quality to assure improvement

• Session 5 – Tuesday, August 7th 2:00 – 3:00 EDT

─ Learn & spread across a community

• Evaluate Cost & Quality Impact

• Prioritize Projects and Manage Organizational Energy

• Create a Portfolio of Projects

• Solve Problems and Execute PDSA Cycles

• Measure and Monitor Results

PRIMARY DRIVERS SECONDARY DRIVERS

Reduce operating

expenses 1% per

year while continually

maintaining or

improving quality.

AIM

WILLAlign Enterprise

WILLEngage Staff, Physicians and Patients

IDEASIdentify Waste

EXECUTIONPrioritize, Manage Portfolio of Projects to Remove Waste

• Establish True North Metrics (Big Dots)

• Align Waste Reduction Strategy Throughout Organization

• Align Systems for Efficiency

• Adopt Integrated Performance Measurement Systems

• Engage Staff in the What & Why of Value Delivery

• Establish Data & Feedback Loops

• Patient & Family Perspective of Waste

• Ensure a Safe Environment for Sharing Ideas

• Develop New Skills at All Levels

• Eliminate Clinical Quality Problems

• Optimize Staffing

• Maximize Flow Efficiency

• Manage Supply Chain

• Reduce Mismatched Services—overuse, coordination

• Reduce Environmental Waste (Healthy Hospital Initiatives)

Driver Diagram IHI’s Cost + Quality Collaborative Work

6/26/2012

35

Thank You